Do rhinoplasties cost more in Hollywood than in other parts of the country?  I suspect they do.  There are several reasons for this.  One is that we do have more superspecialists here performing cosmetic procedures, including rhinoplasty.  Superspecialists tend to command slightly greater fees because of their prominence, their excellence lower rate of re-do or revision surgery.

The cost of doing business is higher in Hollywood than it is in Lincoln, Nebraska or Appleton, Wisconsin.  The labor costs are higher; nurses and surgical assistants command higher wages, all of which are a factor of the higher cost of living in California. Ditto for New York and other centers of excellence.

If one had blepharoplasty and chin augmentation he or she would expect to pay a bit more than you would elsewhere, although not greatly more than in other large cities that have very sophisticated practitioners of cosmetic plastic surgery including New York City, Miami and Houston.

When looking at costs in Hollywood or anywhere else, always be mindful to ask about “the entire cost.”  You need to know what additional costs there would be for the outpatient surgery center, and anesthesia specialists, medications and perhaps even a postoperative recovery facility in which to stay for one or two nights.

I have been thinking a lot about men’s rhinoplasty or cosmetic plastic surgery of the nose, the last several days.  In the last two days we performed nasal cosmetic and reconstructive surgery on two gentlemen.

The first was a middle-aged businessman who had difficulty breathing, but who also was motivated by the fact that he felt his “nose was growing”.   The nose, in fact, doesn’t grow, but the tissues within the nose, the loosen, the tip drops and the nose appears more bulbous and longer.  The gentleman’s motivation for that cosmetic enhancement was proper.  Likewise, the desire to breathe was very reasonable and the patient’s deviated septum and enlarged turbinates were causing blockage such that snoring and poor sleep quality was the result.  So it all made sense. 

In the case of that middle-aged gentleman it was very important to fully understand the man’s wishes.  He expressed on several consultation visits the need to have a natural looking nose that would not look artificial, “done” or drastically different from that which his face had carried for many years.  A surgeon needs to listen carefully to these words and understand the mission.  Any miscommunication could result in an unsatisfactory result and an unhappy patient.  That is not what a conscientious and competent cosmetic facial surgeon wants.

The second nasal case involved a young man who had had two prior nasal surgeries, one for breathing and one for appearance.  The former, the nasal septoplasty, was accompanied by reduction of the turbinates.  The turbinate reduction was quite satisfactory but the septum was still deviated to one side, meaning he had internal nasal blockage because of the shift of the septum which is the vertical partition that separates the two nasal passages.  Those “ revision septoplasty operations are not easy because typically some of the cartilage has been taken out of the septum and there is quite a bit of scar tissue underneath the internal lining of the nose.  It does call for considerable experience, expertise and judgment.

The young man’s other wish was to have his nose appear less long.  Indeed the nose was too long for his face and, as he ages, the length would have only increased.  Apparently the original operating surgeon did not heed the patient’s advice and the result did not match the patient’s wishes.

At this young man’s surgery, very conservative elevation of the nose was done such that it no longer looked too long as if it would touch his lip when he smiled.  And indeed, regarding smile, part of the problem was that he had a very strong muscle which, upon smiling, would depress the tip of the nose further.  The breathing problem was corrected by straightening the septum and some other relatively routine internal procedures, and we were able to lift the nose off the lip, release the muscle which had been exerting its downward force on the lip and give him a natural looking nose which was not radically different from what he had before. But certainly better and in keeping with his desires.

It is very important for surgeons to listen to patients, to get a good sense of what they want.  Also, in my opinion, it’s important have computer imaging available so that the perspective patients can see the predicted results of the procedure that the surgeon deems achievable and reasonable.  A meeting of the minds should take place at the computer imaging session such that the patient and the doctor are on the same page based on that computer visualization of the end result of the cosmetic rhinoplasty.

We have used computer imaging in our practice since 1989. It is helpful and important to patients who need the comfort of seeing the projected outcome.

Unfortunately, the sinuses are the much maligned and much blamed subjects of advertisements for decongestant and allergic nose sprays, pills and an assortment of over-the-counter medications.  The reality is that the sinuses are dependent on the nose function. They need to be filled with air that flows into them from the nose. So it is the nose that really deserves our attention.  Consider the sinuses as anterooms that sit astride the nasal passage as a hallway.  You cannot get into your room if the hallway is blocked.   So if the nasal passages are blocked, you cannot expect the sinuses to function normally.

What happens in the case of abnormal nasal architecture such as the presence of a deviated septum (the vertical partition that separates the right and left nasal passage) is that the airflow is inadequate.  When the airflow is inadequate, then the sinuses do not aerate properly.  They may begin to fill with fluid and ultimately cause symptoms.  The symptoms of true sinus infections are hard to ignore:  headache or facial and tooth pain.  The signs are thick and often pus-like drainage from the nose into the throat. Sometimes bleeding.  Patients have a temperature and even nausea and vomiting. A sickness far worse than a “head cold”.

The best way to keep the sinuses healthy and out of trouble is to not smoke and make sure that your air passages are functioning well.  This calls for an examination by a specialist.  It may be that only allergies need treatment with a prescription steroid or cortisone nasal spray.  But for some patients, surgery is necessary.  The surgery takes less than an hour, has been done for over 100 years and is very well established.  The definitive operation is nasal septoplasty to correct the deviated, crooked or broken nasal septum as well as trimming of the inferior turbinates which are normal outpouchings inside the nasal cavity subject to enlargement either from allergy or other stimulations.

Finally, when patients tell me that they have “three to four sinus infections every year” I know they need help. That is not a normal condition.  True sinus infections should be very rare.

A very savvy business friend of mine said to me several months ago: “I don’t know of anybody who has not been adversely affected by the very difficult economic times now facing the United States.”

Certainly, when the economy is tight, people have less money available for nonessential services such as cosmetic surgery.  Therefore, plastic surgery practices will see decreasing patronage.  For that reason, practices have to be realistic and ask themselves if there is not a way that they can contribute to helping ease the discomfort of a slow economy and at the same time benefit their practice.

I hereby submit that there are three good reasons why a cosmetic plastic surgery practice is wise to lower its fees: 

1. Physicians have a responsibility to help patients.  If economic difficulties present themselves, there is no reason why we cannot soften the blow by reducing our fees.   After all, physicians who treat illness such as internists, pediatricians, surgeons have treated the needy in exchange for diminished fees.  It is a tradition in medical practice that all be served.  Even though our work is not medically necessary, it is still a valuable and important service to patients.  Therefore, it is perfectly consistent with medical ethics that we lower the economic barrier for the sake of our patients.

2. To be most proficient, surgeons need to be busy.  “Beware of the surgeon who operates infrequently” is an ancient and well-respected axiom in the world of surgery.   My experience and that of other superspecialist surgeons is that in fact, the most gifted and proficient surgeons are busy.  They are busy because they attract patients through their talents.  They are also busy because they will accommodate themselves to the needs of the patients including the economic realities.

3. From a purely business standpoint, it is still better for the practice to do a case at a significant courtesy discount than not to do the case at all.  Medical practices have large fixed expenses including rent and staff salaries.  Accountants have long held that for elective surgery, a practice would be foolish not to discount its fees and continue to keep the operating schedule busy rather than take an aloof and distant stance and pass on surgical cases that would otherwise help the practice and the business’s bottom line.

Today a patient came to see me in consultation. He was a young adult who had a history of sustaining a broken nose and having delayed in having it repaired. Finally, unhappy with the appearance and the breathing, he had reconstructive surgery done by a plastic surgeon who was not specialized enough to render the result that might have been achieved. He waited for one year and then had a second surgery by a more specialized surgeon. This “first revision rhinoplasty” according to the operative report was quite complex and intricate. It involved transplanting tissue from the scalp and cartilage from the ear into the nose. Apparently the surgery took five hours. The patient said that it took nearly “two years” for all the swelling to go away. I was somewhat astonished by that initially, but then after reviewing the operative report, and seeing all the maneuvers, techniques and manipulations that were performed, it made sense the operation would take that long.

Before and after photo of another patient of Dr. Kotler who in another state, sustained two prior, yet unsuccessful operations to improve appearance and breathing. Dr. Kotler was able to create a natural nose that worked normally and relieved the patient of her blocked nose and sinus headaches.

Unfortunately for this patient, it did not render satisfaction and thus we are going to have to perform another operation on him. If it were not reasonably predictable that the outcome will be better, I would not consent to perform the surgery. I think it is very important that the “odds” of success be taken into account when performing yet another revisional rhinoplasty surgery.

My assessment is that the operation can be done more simply, efficiently and that this in itself will allow faster healing.

The issue of healing is of major concern for the patient. Because he works with the public he cannot afford to be away from work for weeks and months because the nose and face are so swollen.

Interestingly, and coincidentally, his experience is not unique. Later in the day as I was reviewing a medical magazine, I noticed an article on a young woman who required two revision rhinoplasty operations. Her surgeon noted that “one year post procedure she will be about 30% healed, and only 40% healed after two years.” That is a long time line. Most patients are not happy with the prospect of healing that takes so long.

My point is that it may be that when the operations are done, the techniques involved are just too complicated, too complex and too prone to take so much time to heal that the patient sits in a state of suspended animation for a period far longer than they would like.

I am hearing some amazing stories from patients. While we always learn from listening to our patients, I am not only learning but becoming a bit dismayed with respect to what I am hearing about nasal cosmetic plastic surgery. Patients report operations taking three, four and even five hours that ultimately were unsatisfactory for the patient. It seems the operations become longer as more grafting and transplantation of tissue takes place. Now certainly there are indications for adding on tissue into the nose, particularly if there has been previous surgery or if there has been an accident that has destroyed some of the tissue. But, even if that is the case, why are these operations taking so long? I am not sure of the answer, except, my sense is that some surgeons are making the operation much more complicated and complex than need be. For many of the grafting or transplanting needs, there is adequate tissue inside the nose itself. This of course makes it very economical and efficient to be able to harvest the tissue since it is coming right from the area that we are working on. Often, we use cartilage and bone from the nasal septum because we are taking it out anyway to correct the deviated nasal septum and improve the airway, and correct problems that might lead to sinusitis and other serious complications. While only very rarely is it necessary to take cartilage from the ear, I am now hearing stories of almost routine harvesting of rib cartilage and even rib bone to be place inside the nose, and of course, that makes for a very involved, complicated and long duration operation since other surgical sites besides the nose must be operated upon. I guess I am just from the old school. We do nearly all our surgeries from inside the nose using completely hidden incisions, closed with absorbable stitches. That is called a “closed rhinoplasty“. The “open rhinoplasty” requires an external incision, and I just don’t see the need for that very often. And I have done over 4,000 cases in my career which now spans nearly forty years. The other issue is that some surgeons are not efficient. It just takes them too long to get the job done. I would attribute that to less-than-optimal training in the residency programs as well as inexperience. Generally, inexperienced surgeons are slower than veteran surgeons. The “occasional nasal surgeon”, the doctor who spends more time doing other cosmetic plastic surgeries such as breast augmentation, tummy tuck, breast reduction and liposuction just doesn’t develop the facility for rhinoplasty because he doesn’t operate on the nose often enough. He cannot become a master nasal surgeon. In my experience, most cosmetic nasal surgery or rhinoplasty procedures could be done within an hour. If you need to add on the functional or breathing operation, that adds another 20-30 minutes. The total time in the operating room, including going to sleep and waking up from the anesthetic, should rarely be more than two hours.

Today our patient correspondent and consultant, mentioned a conversation with a patient from Europe. The patient was coming to us to have nose surgery done and seemed a bit put off when told that it was necessary to make all the arrangements ahead of time.  Ideally, the arrangements would include having a Skype consultation with Dr. Kotler so any questions or issues that the patient wanted to present to him could be done before the patient gets on an airplane and travels thousands of miles to come here.  Secondly, after the Skype session, if the decision has been made to have the surgery, it is very important that the patient have a physical exam and the appropriate laboratory and x-ray work done well before surgery.  After all, if there is a medical problem, surgery cannot be performed.  Cosmetic plastic surgery is only done when the patient’s general health condition is excellent.  There can be no compromises.  So if there is a problem, you surely want to know well ahead of time so that schedules can be amended and most importantly the medical problem could be attended to before flying across the pond.

It seemed that the patient thought he could come in on a Monday, have a consultation and go to the operating room on Tuesday.  And maybe that is because he, as others, tend to minimize the importance of a proper pre-operative evaluation and workup and that everything be put in proper order.

There are logistical issues that have to be considered.  We have to reserve the operating room.  We also have to reserve the doctor-anesthesiologist so that everything is properly anticipated and done properly.  Depending on the procedure, necessary supplies and equipment have to be available and that cannot always be done on a one-day’s notice.

Most importantly, Dr. Kotler and the patient must have time together to discuss the patient’s desires either via Skype or, of course, person-to-person when the patient is here.  Our preference, for patient safety and comfort, is that all possible communications and arrangements be made well ahead of time.   And the patient just doesn’t get off the plane and go to the operating room.  There is always a visit with me in the office one or two days before the procedure.  It is important for me to do a complete examination and determine those things that are not possible to determine via Skype and computer imaging, of course.  I want to explain in detail, face to face, how the procedure will be conducted.  I explain to the patient that the anesthesiologist will call the night before, that the patient will see me in the morning, that the patient will have my home phone and cell phone number so that he knows we are ready and prepared to give the patient the care that he or she deserves.

It may be a tribute to cosmetic surgery that people feel that it is a “minor undertaking.”  If it is a tribute, it is because we have been able to handle all the issues such as discomfort and provide for rapid recovery.  But the truth is, we do not treat it with any less importance than a neurosurgeon treats a patient upon whom he will be doing brain surgery.  After all, we trained as long to do our work as the neurosurgeon trained to do his.

Unfortunately, cocaine use is still with us.  There are significant consequences to cocaine abuse.  The worst complication is its effect on the heart and blood vessels which causes high blood pressure that can possibly lead to a stroke – or even death.

Cocaine and Rhinoplasty Surgery Do Not Mix!

There are problems that come with septal perforations:  crusting, whistling and bleeding.  It is a real hassle.  And once that hole is created, it is very difficult to surgically close it.  While there are some appliances that can be inserted to act as a “stopper,” just be aware that one is asking for considerable problems with long-term cocaine abuse.

The other issue is that one should never consider having any cocaine in their body at the time of surgery.  This sets the stage for a possible anesthetic catastrophe!  There can be an unfavorable interaction with the anesthetic drugs as well as the local anesthetics that must be injected. 

Remember, doctors are not judges. We are not an arm of the legal system. Our conversations and records are private and cannot be shared with anyone without your permission.  We don’t have an editorial position on personal choice issues. Our only job is to serve you. However, you need to be frank and honest with your doctor whose only aim is to have a safe surgery and a satisfactory outcome for his patient.

Revision rhinoplasty is common in Beverly Hills because there is a certain percentage of patients who are unhappy with their surgery previously performed elsewhere.   Here in Beverly Hills, where we have several surgeons with a long track record of experience and superspecialization, patients congregate to have the more the difficult nasal surgeries performed.

One of the more common consequences of an overzealous or overdone rhinoplasty is that the nose is “too short.”  The nose tips up and the angle between the nose and the lip is so great that sometimes it looks like the nostrils may fall prey to a thunderstorm.   Perhaps there was inadequate surgery done at the junction between the nose and the lip. This can be improved.  The nasal spine and the caudal septum, whether straight or deviated, may be altered and that sharpens the nose-lip angle. This makes the nose look much less pug or upturned.  If that is not an option, cartilage can be transplanted just behind the tip to push it forward.  Another technique is to use a filler to plump the skin of the tip just between the opening to the nostrils and this again leads to a more satisfactory nose-lip angle.  Also remember that a nose looks overly-short if the bridge has been taken down too much.  If the nose has that overdone ski-slope look, filling this defect either with a cartilage graft or even with office-performed filling injections will raise the bridge and make the nose look much less short. 

Understand that much of what we do has to do with illusions and appearances – small differences can make a big difference.

A rhinoplasty saddle nose occurs because the internal supports have been weakened or removed.  The upper bridge of the nose is bone but the lower portion of the bridge of the nose is cartilage.  If too much of the septum underneath either is removed, there will be a collapse of the bones and/or collapse of the upper lateral cartilages which rests upon the septum and when they “fall” into the nose, the outside appearance looks like a saddle. 

Assuming that the breathing has not been impaired, the correction is by insertion of the patient’s own or transplanted tissue.  Some surgeons prefer bone.  Others prefer cartilage and some use another material, from under the skin, called fascia.  Or one can insert a custom-made or custom-trimmed prosthetic part.  Generally these are solid medical-grade silicone, the same material that is used in artificial heart valves and artificial joints.  It can be sculpted to the size of the saddle-depression and then tucked underneath the skin through internal nasal incisions. Afterwards, there is no saddle and the profile is straight.  But an alternative is filling injections.  Temporary injections are fine but most patients coming to Beverly Hills for revision rhinoplasty certainly are also offered the possibility of a permanent filling injection.   Medical grade liquid silicone which has been used in the United States for over 50 years, in droplet form, is a very practical solution to correcting a saddle nose post-rhinoplasty.